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A healthcare professional is planning to administer IV Alteplase to a client who is demonstrating manifestations of a massive Pulmonary Embolism. Which of the following interventions should the healthcare professional plan to take?
- A. Administer IM Enoxaparin along with the Alteplase dose.
- B. Hold direct pressure on puncture sites for up to 30 min.
- C. Administer Aminocaproic acid IV prior to alteplase infusion.
- D. Prepare to administer Alteplase within 8 hr of manifestation onset.
Correct Answer: B
Rationale: The correct intervention when administering IV Alteplase is to hold direct pressure on puncture sites for 10 to 30 minutes or until oozing of blood stops. This helps prevent bleeding complications associated with thrombolytic therapy. Administering IM Enoxaparin is not indicated with Alteplase, as it is an anticoagulant rather than a thrombolytic agent. Aminocaproic acid is not typically administered prior to alteplase infusion in the context of a massive Pulmonary Embolism. While timely administration of Alteplase is important, the specific timeframe within which it should be administered may vary based on the clinical situation, so a strict 8-hour window is not universally applicable.
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A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Take one tablet at the first sign of chest pain.
- B. If pain is not relieved, take another tablet in 10 minutes.
- C. You can take up to five tablets in 15 minutes.
- D. Swallow the tablet with water.
Correct Answer: A
Rationale: The correct instruction for a client with a new prescription for nitroglycerin sublingual tablets is to take one tablet at the first sign of chest pain. If the pain is not relieved after 5 minutes, the client should call 911 and take a second tablet. Taking more than the recommended dose can lead to serious side effects, and swallowing the tablet would not provide the rapid effect needed in cases of chest pain. Choice A is correct because it aligns with the standard protocol for nitroglycerin use in treating angina. Choice B is incorrect as the second tablet should be taken after 5 minutes, not 10 minutes. Choice C is incorrect as taking up to five tablets in 15 minutes is excessive and can result in serious complications. Choice D is incorrect as nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not swallowed.
A client has a prescription for Phenytoin. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Increase your intake of calcium-rich foods.
- C. Brush and floss your teeth regularly.
- D. Avoid eating foods high in potassium.
Correct Answer: C
Rationale: The correct answer is C: 'Brush and floss your teeth regularly.' Phenytoin can cause gingival hyperplasia, a condition that leads to overgrowth of gum tissue. Good oral hygiene practices such as regular brushing and flossing can help prevent or minimize this side effect. In contrast, choices A, B, and D are not directly related to managing the side effects of Phenytoin. Taking the medication at bedtime (choice A) is not a specific instruction related to oral hygiene. Increasing calcium-rich foods intake (choice B) may be beneficial for bone health but is not directly related to preventing gingival hyperplasia. Avoiding foods high in potassium (choice D) is not a necessary instruction for a client taking Phenytoin.
A client is receiving imatinib. Which of the following adverse effects should the nurse monitor?
- A. Edema
- B. Constipation
- C. Dry mouth
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Edema. The nurse should monitor the client for edema when receiving imatinib. Imatinib, a tyrosine kinase inhibitor, can lead to fluid retention and edema as a common adverse effect. This can manifest as swelling in various parts of the body, indicating the need for close monitoring by the nurse to prevent complications related to fluid overload. Choices B, C, and D are incorrect because constipation, dry mouth, and urinary retention are not typically associated with imatinib use. Therefore, they are not the priority adverse effects to monitor in a client receiving this medication.
A client has a new prescription for Digoxin to treat heart failure. Which of the following instructions should the nurse include in the teaching?
- A. Contact the provider if the heart rate is less than 60/min.
- B. Check the pulse rate for 30 seconds and multiply the result by 2.
- C. Increase the intake of sodium.
- D. Take with food if nausea occurs.
Correct Answer: A
Rationale: The correct answer is A. It is crucial for clients on Digoxin to monitor their heart rate. A heart rate less than 60/min can indicate bradycardia, a potential side effect of Digoxin. Therefore, the client should be instructed to contact the provider if their heart rate is less than 60/min to prevent complications and receive appropriate management. Choices B, C, and D are incorrect. Checking the pulse rate for 30 seconds and multiplying by 2 is not specific to Digoxin administration. Increasing sodium intake is contraindicated as Digoxin can lead to sodium retention. Taking Digoxin with food if nausea occurs is not recommended as it may affect the drug's absorption.
A healthcare provider is planning to administer IV Alteplase to a client who is demonstrating manifestations of a massive Pulmonary Embolism. Which of the following interventions should the healthcare provider plan to take?
- A. Administer IM Enoxaparin along with the Alteplase dose.
- B. Hold direct pressure on puncture sites for up to 30 minutes.
- C. Administer Aminocaproic acid IV prior to alteplase infusion.
- D. Prepare to administer Alteplase within 8 hours of manifestation onset.
Correct Answer: B
Rationale: When administering IV Alteplase for a massive Pulmonary Embolism, the healthcare provider should plan to hold direct pressure on puncture sites for 10 to 30 minutes or until oozing of blood stops. This is crucial to prevent bleeding complications at the puncture sites. Choice A is incorrect because Enoxaparin is not usually administered along with Alteplase for a Pulmonary Embolism. Choice C is incorrect because Aminocaproic acid is not typically given prior to alteplase infusion in this situation. Choice D is incorrect because Alteplase should be administered within 2 hours of onset of manifestations for Pulmonary Embolism, not within 8 hours.